General Information Denis, Africa s leading dental funder, manages your dental benefits on behalf of your medical scheme.

Transcription

1 Dental Benefit Information for 2011

2 General Information Denis, Africa s leading dental funder, manages your dental benefits on behalf of your medical scheme. There is a pre-defined benefit per procedure which is paid at the published Scheme tariff. Your dentist will also be able to provide information regarding your benefits, as Denis supplies all dentists with a Chairside Guide, which illustrates the Dental Benefits for Benefits for Dentistry are paid on a fee for service basis. This means that for every procedure done by a dentist there is a fee that is charged. These fees may differ from dentist to dentist. Your scheme pays a benefit for each procedure which may differ from the fee charged by your dentist. It is your right to negotiate this difference with your dentist. Please familiarise yourself with the defined benefits before visiting your dentist. By doing so, you will be fully aware of what your scheme will pay toward your treatment. You are eligible for benefits, irrespective of which dentist treats you. The following information illustrates how your benefits are structured so that you know before your treatment is rendered, what is covered and what is not. For clinical definitions, please log onto Conservative Dentistry All conservative dental benefits are covered at the Scheme tariff. How many check-ups do I have benefit for? Two general check-ups (consultations) are covered at the NHRPL tariff, per beneficiary per year. What benefits does the scheme provide in respect of fillings, extractions and root canal treatment? For extensive restorative treatment plans (multiple fillings), a treatment plan and x-rays may be requested. Benefit for re-treatment of a tooth with an additional filling within the 365 days is subject to clinical protocols. Benefit for fillings to restore teeth damaged due to toothbrush abrasion or attrition is subject to clinical protocols Extractions and root canal treatments are covered, as required, at the Scheme tariff. 01

3 What denture benefit is available? Plastic Dentures There is benefit for one set of plastic dentures (an upper and a lower) per beneficiary in a four year period. Partial Metal Frame Dentures There is benefit for two metal frames (an upper and a lower) per beneficiary in a five year period. Note: Full metal dentures are not covered. Specialised Dentistry The following specialised dental benefits must be pre-authorised: Crown and Bridge procedures Orthodontics Implants Hospitalisation Intravenous Conscious Sedation. What is pre-authorisation? Benefit pre-authorisation is the prior approval of any of the above listed specialised dental treatments. How do I get pre-authorisation? Please call Once authorisation has been obtained, cover for the treatment is subject to scheme rules and benefit protocols. What happens if I fail to apply for pre-authorisation? If no pre-authorisation is obtained, or if pre-authorisation is applied for after the treatment has been done, no benefit for such treatment will be paid. This does not apply to emergency hospital admission. Crowns Benefit for crowns is subject to pre-authorisation, where clinical protocols apply. This benefit will only be granted once per tooth in a five year period and is covered at the Scheme tariff. How many crowns do I have benefit for? Crowns are limited in quantity per family, regardless of the type of crown being placed. There is benefit for three crowns per family per year. 02

4 Crown and bridge treatments that are NOT covered by the scheme: Laboratory fabricated crowns on primary teeth Fixed prosthodontics (crowns) used to repair teeth damaged due to bruxism (tooth grinding); toothbrush abrasion or attrition; erosion or fluorosis Fixed prosthodontics used to restore teeth for cosmetic reasons Fixed prosthodontics where a reasonable attempt has not been made to restore/replace the tooth conservatively Fixed prosthodontics where the member s mouth is periodontally compromised Fixed prosthodontics where the tooth has been recently restored to function Fixed prosthodontics (crowns) where the tooth is unopposed/non-functional. Note: All pre-authorisation requests for crown and bridge benefits must be accompanied by clear clinical records (x-rays of the teeth to be treated). Orthodontics What orthodontic benefit is available on my option? Benefit on pre-authorisation will only be applied to cases assessed as treatment mandatory, as per orthodontic indices. Authorised benefits are payable to a maximum of R per beneficiary per lifetime. A deposit is paid at the start of treatment and the balance is paid over the estimated treatment period. Orthodontic benefit protocols Benefits for orthodontic treatment are only available to beneficiaries whose treatment commences before their eighteenth birthday. Only one family member may commence orthodontic treatment in a calendar year, except in the case of identically aged siblings. Orthodontic re-treatment is not covered. Orthognathic (jaw correction) surgery and the associated hospital admission is not covered. Dental Implants Do I have benefit for dental implants? There is benefit for two implants per beneficiary in a five year period. This is subject to pre-authorisation. Cost of implant components is limited to R1 500 per implant. Note: All associated procedures, including hospitalisation and surgery are not covered for implantology. 03

5 Periodontics Periodontal benefit is only available to members who are registered on the Perio Programme. This benefit is restricted to conservative, non-surgical therapy only (root planing). How do I apply for registration on the Perio Programme? Send your CPITN score (supplied to you by your dental practitioner), together with your periodontal treatment plan and x-rays to perio@denis.co.za or alternatively fax to Further information may be requested in order to process your application. Periodontal benefits will only be applied to cases assessed as periodontally compromised. After the treatment plan and x-rays have been assessed and periodontal benefit authorised, an authorisation letter will be sent to your treating dental practitioner. Note: Surgical periodontics is not covered. Oral Surgery Oral Surgery in the dental chair: Oral Surgery in the dental chair is covered at the Scheme tariff. Oral Surgery in hospital: See General Anaesthetic and Hospitalisation on page 05. General Surgery Exclusions Surgical procedures (in the dental chair and in hospital) that are not covered by the scheme: Bone Augmentations Sinus Lifts Bone and Tissue regeneration Gingivectomies Surgical procedures associated with dental implantology Dental Anxiety Some people are anxious about dental treatment and mild sedation may be required. Benefits are payable for sedation methods such as laughing gas or sedative medications. No pre-authorisation is required for laughing gas or sedative medications. Conscious sedation (IV sedation) is subject to pre-authorisation where clinical protocols apply. Note: Hospitalisation and general anaesthesia is not covered where patients require anxiety control. 04

6 General Anaesthetic and Hospitalisation Hospitalisation benefit for dentistry is not automatically covered and is subject to pre-authorisation, where admission protocols apply. What dental procedures are covered in hospital? Certain maxillo-facial procedures are covered in-hospital subject to pre-authorisation, where admission protocols apply. See Exclusion Summary on page 08. In-hospital dental treatment for children General anaesthetic benefits are available for very young children who require extensive dental treatment (multiple extractions and fillings), subject to admission protocols. Note: Multiple hospital admissions are not covered. Hospitalisation admission protocols Multiple hospital admissions are not covered. Removal of impacted teeth in hospital will only attract benefit where the teeth are impacted by bone. Where the x-ray illustrates that the teeth are not impacted, are impacted by soft tissue only or that their position does not complicate removal thereof, hospital admission will not be authorised. 05

7 Hospital benefit for the removal of a single impacted tooth is not available. Hospitalisation is not covered where anxiety of dental treatment is the reason for the admission. The requirement of a sterile facility is not an acceptable reason for hospitalisation benefit for dental treatment. Where a member has a history of an allergy to local anaesthetic, a pathology report will be required. General in-hospital exclusion summary The following procedures are not covered in hospital. The member is liable for the full account. Apisectomies Dentectomies Frenectomies Implantology and associated surgical procedures Conservative dental treatment (fillings, extractions and root canal therapy) for adults Professional oral hygiene procedures IV Conscious Sedation for dental implantology Surgical tooth exposure for orthodontic reasons How to get authorisation before going to hospital Contact us on at least 48 hours prior to the planned procedure. Please have the following information ready when you phone us: Your PG Group membership number The date of admission Name of the practitioner, a contact telephone number and practice registration number The anaesthetist s practice number and contact details The name and telephone number of the hospital All relevant procedure codes and applicable tooth numbers In certain instances an x-ray or clinical report will be requested in order to process your pre-authorisation. If the hospital admission is authorised, you will be supplied with an authorisation number via your preferred method of communication (fax or ). The hospital account will be paid at the Rand value, stipulated on the authorisation letter. Hospital accounts exceeding this amount will be the member s responsibility. In the event of an after hours emergency, please let us know about your hospitalisation as soon as possible. Note: If you do not obtain authorisation before your hospital admission, the associated costs (hospital and anaesthetic accounts) will not be paid. 06

8 General Benefit Exclusion Summary The following treatment is not covered. The member is liable for the total cost of these procedures: Oral hygiene instructions Professionally applied topical fluoride in adults Nutritional and tobacco counselling Caries susceptibility and microbiological tests Electrognathographic recordings and other such electronic analyses Fissure sealants on patients older than 16 years Pulp capping (direct and indirect) Polishing of restorations Ozone therapy Metal base to full dentures (including the laboratory cost) Diagnostic dentures Provisional crowns Laboratory cost of provisional and emergency crowns Resin bonding for restorations charged as a separate procedure Dental bleaching, porcelain veneers and inlays Gingivectomy Periodontal flap surgery, tissue grafting and hemisection of a tooth Perio Chip Orthodontic re-treatment the related hospital cost Orthognathic (jaw correction) surgery and the related hospital cost Sinus lifts Bone augmentations Bone and other tissue regeneration procedures Dolder bars and associated abutments on implants (including the laboratory cost) Snoring appliances High impact acrylic Cost of Mineral Trioxide Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments Cost of gold, precious metal, semi-precious metal and platinum foil Cost of invisible retainer material Cost of bone regeneration material Laboratory delivery fees Cost of dental materials in hospital. 07

9 Supplementary Protocols Fillings For extensive restorative treatment plans (multiple fillings), a treatment plan and x-rays may be requested. Benefit for re-treatment of a tooth with an additional filling within the 365 days is subject to clinical protocols. Benefit for fillings to restore teeth damaged due to toothbrush abrasion or attrition is subject to clinical protocols. Crown and Bridge Benefits for crowns will be granted once per tooth in a five year period. Benefits for crowns/bridges will not be applied toward the following cases: Laboratory fabricated crowns on primary teeth Fixed prosthodontics (crowns) used to repair teeth damaged due to bruxism (tooth grinding); toothbrush abrasion or attrition; erosion or fluorosis Fixed prosthodontics used to restore teeth for cosmetic reasons Fixed prosthodontics where a reasonable attempt has not been made to restore/replace the tooth conservatively Fixed prosthodontics where the member s mouth is periodontally compromised Fixed prosthodontics where the tooth has been recently restored to function Fixed prosthodontics (crowns) where the tooth is unopposed/nonfunctional. Hospital Claims for oral pathology procedures (cysts, biopsies, surgical treatment of tumours of the jaw and soft tissue tumours) must be accompanied by a laboratory report. Closure of oral-antral fistula (currently code 8909) may not be claimed during the same visit with impacted wisdom. teeth (currently codes 8941, 8943 and 8945). Hospital benefit for dental treatment will not be granted where the only reason for admission is the requirement of a sterile facility. Hospital benefit for dental treatment, in the case of an allergy to local anaesthetic, will only be granted where a positive allergy to local anaesthetic is indicated by a pathology report (CAST test). 08

10 The following treatment does not attract benefit in hospital: Apisectomies Dentectomies Implantology and associated surgical procedures Conservative dental treatment for adults (fillings, extractions and root canal therapy) Professional oral hygiene procedures IV Conscious Sedation for dental implantology Surgical tooth exposure for orthodontic reasons Periodontics Periodontal benefits will only be applied to cases assessed as periodontally compromised (accompanied by increased pocket depths, bone loss and possible furcation involvement). The CPITN is used for assessment and benefits are granted accordingly. Orthodontics Benefits for Orthodontic treatment are only available to beneficiaries whose treatment commences before their eighteenth birthday. Only one beneficiary per family may commence orthodontic treatment in a calendar year. Note: In the event of a dispute regarding the benefit information illustrated herein, the Rules of the scheme will prevail. 09

11 Denis Oral Health Programme Denis offers an Oral Health Programme to all PG Group medical scheme members. This free service supplies the member with oral health information in an electronic format and focuses on member education. All information is easy to understand and ranges from dental articles to interactive videos for children. The Denis Network The Denis Network of dental service providers offers the PG Group medical scheme member conservative dental treatment, with no self-funding (out of pocket payment). PG Group medical scheme covers dental treatment up to the Scheme s Dental Benefit Rate (SDBR). Self funding is when a dental service provider charges fees that are above the SDBR and the member is liable to pay the difference to the service provider. As all the dental service providers on the Denis Network only charge a defined rate, you will not have to pay for conservative dental treatment out of your own pocket. This includes the following treatment: Consultations Oral hygiene procedures Fillings Root canal treatment Extractions X-rays To find a Denis Network service provider in your area, please feel free to contact Denis on Alternatively, you may visit our website

12 2011 PG Group Dental Benefits Dental benefits are paid at the Scheme s Dental Benefit Rate (SDBR). All specialised dentistry and hospitalisation must be pre-authorised*. If no pre-authorisation is obtained or if pre-authorisation is applied for after the treatment has been done, benefits will not apply. This does not apply to emergency hospital admissions. Dental benefits are subject to clinical protocols and Managed Care Interventions, which may include the requirement of treatment plans and/or radiographs prior to benefit application. Scheme exclusions apply to dental benefits. In the event of a dispute, the Rules of the Scheme prevail. DENTAL BENEFITS Conservative Dentistry Consultations 2 annual check-ups per beneficiary. Benefit is subject to clinical protocols. SDBR tariffs apply. X-Rays: Intra-oral Benefit is subject to clinical protocols. SDBR tariffs apply. Scheme exclusion: Electrognathographic recordings. X-Rays: Extra-oral 1 per beneficiary in a 3 year period. Benefit is subject to clinical protocols. Additional benefit may be considered where specialised dental treatment is required. SDBR tariffs apply. Oral Hygiene 2 annual scale and polish treatments per beneficiary. Benefit is subject to clinical protocols. Benefit for fissure sealants is limited to individuals younger than 16 years of age. SDBR tariffs apply. Scheme exclusions: Oral hygiene instructions; Oral hygiene evaluation; Professionally applied adult fluoride; and Dental bleaching. Fillings Benefit for re-treatment of a tooth is subject to clinical protocols. SDBR tariffs apply. Scheme exclusions: Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and fluorosis; Resin bonding for restorations that are charged as a separate procedure to the restoration; The polishing of restorations; Gold foil restorations; and Ozone therapy. Root Canal Therapy Extractions Plastic Dentures Partial Metal Frame Dentures Benefit is subject to clinical protocols. SDBR tariffs apply. Scheme exclusion: Direct and indirect pulp capping procedures. 1 set of plastic dentures (an upper and a lower) per beneficiary in a 4 year period. Benefit is subject to clinical protocols. SDBR tariffs apply. Benefit is not available for the clinical fee of denture repairs, denture tooth replacements and the addition of a soft base to new dentures; the laboratory fee will be covered. Benefit is not available for the laboratory fee of mouthguards; the clinical fee will be covered. Scheme exclusions: Diagnostic dentures and associated laboratory costs; Snoring appliances and associated laboratory costs; High impact acrylic; The cost of gold, precious metal, semi-precious metal and platinum foil; and Laboratory delivery fees. 2 partial frames (an upper and a lower) per beneficiary in a 5 year period. Benefit is subject to clinical protocols. SDBR tariffs apply. Scheme exclusions: The metal base to full dentures and associated laboratory costs; High impact acrylic; The cost of gold, precious metal, semi-precious metal and platinum foil; and Laboratory delivery fees. 11

13 Specialised Dentistry Crown and Bridge * and associated Laboratory costs A bridge comprises of 2 or more crowns. Each crown is payable from the available Crown and Bridge benefit. Implants* Orthodontics* and associated Laboratory costs Periodontics* Maxillo-Facial Surgery and Oral Pathology DENTAL BENEFITS Pre-authorisation is required. 3 crowns per family per year. Benefits for crowns are granted once per tooth in a 5 year period. Benefit is subject to clinical protocols. SDBR tariffs apply. Scheme exclusions: Crown and bridge procedures for cosmetic reasons and associated laboratory costs; Full mouth rehabilitations and associated laboratory costs; Provisional crowns and associated laboratory costs; Porcelain veneers and inlays and associated laboratory costs; Emergency crowns that are not placed for the immediate protection in tooth injury and associated laboratory costs; The cost of gold, precious metal, semi-precious metal and platinum foil; and Laboratory delivery fees. Pre-authorisation is required. 2 implants per beneficiary in a 5 year period. Cost of implant components is limited to R1 500 per implant. Benefit is subject to clinical protocols. SDBR tariffs apply. Scheme exclusions: Dolder bars and associated abutments on implants including the associated laboratory costs; and Laboratory delivery fees. Pre-authorisation is required for Removable appliance therapy; Functional appliance therapy; Partial fixed appliance therapy (pre-liminary treatment); and Comprehensive fixed appliance therapy. Benefit is subject to clinical protocols. Authorised benefits are payable to a maximum of R per beneficiary per lifetime. On pre-authorisation cases will be clinically assessed using orthodontic indices. Benefit for Orthodontic treatment will be granted where function is impaired. Benefit will not be granted where Orthodontic treatment is required for cosmetic reasons. The associated Laboratory costs will also not be covered. Only one family member may commence Orthodontic treatment in a calendar year. Benefit is limited to individuals younger than 18 years of age. Scheme exclusions: Orthodontic re-treatment and any related Laboratory costs; Orthognathic (jaw correction) surgery and any related hospital cost including associated Laboratory costs; Invisible retainer material; and Laboratory delivery fees. Pre-authorisation is required. Benefit is subject to clinical protocols. SDBR tariffs apply. Benefit is limited to conservative, non-surgical therapy only (root planing) and will only be applied to members who are registered on the Perio Programme. Scheme exclusions: Surgical periodontics which includes gingivectomies, periodontal flap surgery tissue grafting and the hemisection of a tooth; and Perio chip placement. Surgery in the dental chair: Benefit is subject to clinical protocols. SDBR tariffs apply. Benefit for Temporo-mandibular Joint (TMJ) therapy is limited to non-surgical intervention/treatments. The claims for oral pathology procedures (cysts and biopsies, the surgical treatment of tumours of the jaw and soft tissue tumours) will only be covered if supported by a laboratory report that confirms diagnosis. Scheme exclusions: Orthognathic (jaw correction) surgery; Sinus lifts; Bone augmentations; Bone and tissue regeneration procedures; The cost of bone regeneration material; and The auto-transplantation of teeth; The closure of an oral-antral opening (currently code 8909) when claimed during the same visit with impacted teeth (currently codes 8941, 8943 and 8945) is a scheme exclusion. Surgery in hospital: See Hospitalisation* on next page. 12

14 2011 PG Group Dental Benefits continued Hospitalisation and Anaesthetics Hospitalisation (general anaesthetic*) Laughing gas in dental rooms IV conscious sedation in rooms* DENTAL BENEFITS Pre-authorisation is required. Admission protocols apply. General anaesthetic benefits are available for very young children for extensive dental treatment. General anaesthetic benefits are available for the removal of impacted teeth; benefit will be granted where the teeth are covered by bone. The hospital and anaesthetist claims for the following procedures will not be covered when performed under general anaesthesia. The payment of the dental procedure will be dependent on available benefits and payable at SDBR tariffs: Soft tissue impactions Apicectomies Dentectomies Frenectomies Implantology and associated surgical procedures Conservative dental treatment (fillings, extractions and root canal therapy) for adults Professional oral hygiene procedures Surgical tooth exposures for orthodontic reasons Scheme exclusions: Where the only reason for admission to hospital is dental fear and anxiety; Multiple hospital admissions; Where the only reason for the admission request is for a sterile facility; and The cost of dental materials for procedures performed under general anaesthesia. Benefit is subject to clinical protocols. SDBR tariffs apply. Pre-authorisation is required. Benefit is subject to clinical protocols. SDBR tariffs apply. Benefit is limited to extensive dental treatment. Additional Scheme Exclusions: Nutritional and tobacco counselling Caries susceptibility and microbiological tests Cost of Mineral Trioxide Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments Appointment not kept Special report Dental testimony Enamel microabrasion Behaviour management Intramuscular or subcutaneous injection Procedures that are defined as unusual circumstances and procedures that are defined as unlisted procedures 13

15 Get your claims to Denis Post the original copies of your dental claims to: Private bag X 1 Century City Cape Town 7446 Alternatively, you can your dental claims to claims@denis.co.za. When submitting a claim, please ensure the following details are clearly visible: Your PG Group membership number The dentist s details and practice registration number The correct dependant code (see your membership card) The treatment date The relevant procedure codes The applicable tooth numbers The relevant ICD-10 code If you have already paid for the treatment, kindly ensure that the appropriate receipt is attached. Stale claims Claims that are not received within four months of date of treatment are, in terms of the Medical Schemes Act, regarded as stale and will not be eligible for benefit/payment. 14

16 Denis Contact Details Call Centre telephone number Call Centre fax number Contact Addresses Enquiries Claims Crowns Hospital Authorisations Orthodontic Authorisations Implant Authorisations